The Multiple Advocacies of the Veterinarian and Conflicting Interests

A fundamental ethical problem in veterinary practice is whether veterinarians should give primary consideration to the animal or to the client/animal owner (Rollin 2006a; Kipperman et al. 2018). Acknowledging this, Tannenbaum observes that veterinarians are “the servants of two masters” (1995). Rollin makes the distinction between two models of veterinarians: the pediatrician model, which is characterized by patient advocacy, and the model of the mechanic, beholden to client requests and demands regarding the disposition of their legal property (2006a).

It is assumed by animal owners and by society that veterinarians are advocates for animals. The reputation of the veterinary profession is inherently connected to its consideration and treatment of animals (Weich and Grimm 2018). Hughes et al. (2018) found that British and Australian veterinary clients considered the most important objective that veterinarians should pursue is a dedication to the well-being and quality of life of the patient. Rollin (2004) asserts that “It is … a major part of veterinary medicine to defend the interests of animals.”

One of the main impediments to animal advocacy is that veterinarians are hired by humans, not by animals (Sandøe et al. 2008). Veterinarians need to contend with clients’ desires and wishes: veterinary decisions are increasingly shaped by these client-centered variables (Springer et al. 2019). In an ethnographic study of small animal veterinarians in the United States, Morris concludes that, “The role of the veterinarian is to provide a list of options for the pet owner …, leaving nearly every decision regarding their … patients entirely in the hands of the client” (2012). In this paradigm, the veterinarian is a medical counselor who forms a relationship with and works on behalf of the animal owner. Main acknowledges this model and asks:

Since the client makes the decision, what contribution does the veterinary surgeon actually make? The veterinary surgeon decides what should be offered or recommended to the client. The emphasis on the client’s role in the process is made very clear in the RCVS Guide to Professional Conduct, which states that “veterinary surgeons must accept that their own preference for a certain course of action cannot override the client’s specific wishes other than on exceptional welfare grounds.”

(2006)

Consequently, veterinarians may seek to promote client autonomy in lieu of patient interests. One might believe that the fundamental responsibility of a veterinarian is to obey client decisions even to the detriment of the medical interests of patients (short of breaching cruelty laws) (Coghlan 2018). Moreover, any interventions legally and ethically require informed consent from the client.

Another obstacle discouraging the animal advocacy position is economic: the veterinarian is dependent on the animal owner who pays for veterinary services (Main 2006; Dürnberger 2020). Tannenbaum (1995) claims that veterinarians are obliged to serve client interests primarily because they are paying for such services. Consequently, a common practice philosophy is that profitability is commensurate with client satisfaction. Also, veterinarians in practice are commonly compensated based on a proportion of their revenues (Opperman 2019). Although such systems are purportedly intended to reward those seeing many patients, these also create an incentive for the veterinarian to advise costly testing, procedures, hospitalization, and surgery. Consequently, an implicit conflict of interest exists that may influence veterinary recommendations, contributing to unnecessary treatment (Rosoff et al. 2018). After sociological research of veterinary practices in the Netherlands, Swabe asserts: “The notion that profit may possibly influence veterinary decision-making … conflicts strongly with the collective image of the … animal doctor that we hold. In deciding the course of action to take, practical and financial considerations may well often outweigh sentiment and idealism” (2000). This conflict of interest is also perceived by clients, as 30% of pet owners agreed that veterinarians advise additional services to make money (Brown 2018).

Unfortunately, all owners do not meet their moral and legal duties to take care of their animals (Main 2006). Then, what is the responsibility of the veterinarian when they believe the decision the owner reaches is not in the animal’s best interest? It can be difficult and uncomfortable for veterinarians to confront owners in these circumstances: some may not consider this as within their purview (Sandøe et al. 2008). With regard to the responsibility of the veterinarian when faced with these types of conflicts, Tannenbaum proposes an animal advocacy role, claiming that: “A [veterinarian’s] …obligation to permit a client to make the decision about care for the patient does not preclude the doctor from presenting oneself as an advocate for the animal and offering on its behalf arguments against the apparent tendencies of the client” (1995). Main also argues in support of the animal advocacy position:

Do veterinary surgeons need to worry about causing distress (in this case, guilt) to clients concerning the cost of treatments? I would argue that … the obligation to the animal’s best interest is greater than a concern for the psychological well-being of the client. If we placed a higher value on clients’ sensitivities, then our duty as animal advocates would not be fulfilled.

(2006)

Results of a survey supported an animal advocacy posture, as 96% of Australian veterinary students agreed that their primary focus as a veterinarian should be the interests of the animals in their care (Verrinder and Phillips 2014). Morris found that many veterinarians feel compelled to advocate for the best interests of animals, just as pediatricians are expected to advocate for the best interests of children (2012). But the author concludes that adoption of this posture is rare in practice: “Because animals are legally considered property and veterinarians depend on clients for income, veterinary medicine is more client oriented than patient oriented… Because veterinarians are more likely to be subject to client demands, veterinarians are … client-dependent professionals” (Morris 2012).

Many clients desire and select the best veterinary care for their animals. In a utopian view of veterinary practice, a model of shared decision-making occurs, in which the interests of the patient and human family are aligned and pursued (Coghlan 2018). Unfortunately, exceptions to this ideal are common in veterinary practice. Although most of the conflicts encountered by veterinary professionals involve the interests of the client and animal, a list of the factors that impact decision-making regarding patients would also include the veterinarian’s interest in performing or learning procedures and professional advancement, their interest in making money, and the expectations from their employer to generate income (Table 7.1).

Differences Between US and UK Codes of Conduct

The American Veterinary Medical Association (AVMA) Veterinarian’s Oath provides no guidance in prioritization of a veterinarian’s varied obligations: “I … swear to use my scientific knowledge … for the benefit of society through the protection of animal health and welfare, the prevention and relief of animal suffering, … and the advancement of medical knowledge” (AVMA n.d.). In contrast, the Royal College of Veterinary Surgeons (RCVS) Oath emphasizes patient advocacy: “I will … accept my responsibilities to … my clients, the profession … and that, ABOVE ALL, my constant endeavour will be to ensure the health and welfare of animals committed to my care” (RCVS n.d.).

Types of Animal Patients

Veterinarians see patients in differing contexts with differing sets of expectations, which may influence the type and extent of care a patient may receive. As an example, a companion animal viewed as a family member who sleeps in the bed may be expected to receive a more thorough level of care compared to a guard dog, who may receive better care than a farm animal, who may be viewed as an economic asset, or a rodent in a laboratory contributing to scientific knowledge. In laboratory animal and farm animal practice, veterinary services are often intended to aid humans and society rather than the animals (Grimm et al. 2018). Even in companion animal practice, some procedures (i.e. declawing) do not promote animals’ health-related interests. Huth observes these inconsistencies:

So, being a patient in veterinary medicine … can have different meanings with different ethical implications. While companion animals are often treated with high effort and costs to … sustain their well-being, livestock animals are not exclusively treated with regards to their well-being but also to sustain productivity. The expectations on the part of the owner, but also social expectations differ significantly. However, in both cases the animal remains a patient …, but they are different kinds of patients.

(2020)

Regarding the responsibility of veterinarians toward animal patients, there are unavoidable comparisons with human medicine, especially in terms of ethical duties (Rollin 2006a). It is generally believed that physicians will (almost) always advocate for their patients, diminishing their interests and the interests of others. This norm arises from the Hippocratic Oath (Coghlan 2018). Medical decisions on behalf of children are made by parents acting as their agent, with legal engagement only when the decision is deemed to be harmful to the child’s welfare (Gray et al. 2020). A recent essay suggests that companion animals are comparable with dependent children: treatment decisions are made by their owners presumably on their behalf (Gray and Fordyce 2020). Considering the obvious challenges in obtaining informed consent directly from animals and instead relying on human presumptions of their preferences (Franks 2019), comparisons with infant children may be more apt, as their desires cannot be surmised as easily (Rollin 2002; Ashall et al. 2018).

Why the Profession of Veterinary Medicine Is Fraught with Ethical Concerns

There are a myriad of reasons that veterinary professionals are more likely to encounter ethical conflicts compared with those working in the human medical field. These disparities exist both within the profession itself, as well as between veterinary professionals and their clients, and include differences in beliefs regarding:

• The importance or value of animals
  
• Human responsibilities to animals
  
• The best interests of animals
  
• The primary allegiance of the veterinarian
  
• The influence of money on decision-making
  
• The legal status of animals as property.

(modified from Morgan and McDonald 2007)

What Is an Ethical Dilemma?

Ethical dilemmas arise when there are competing interests of perceived equal moral weight, and there is a lack of clearly defined rules to prioritize these, i.e. it is not clear what is the “right thing to do” (Morgan and McDonald 2007). Ethical dilemmas can involve the recognition of two or more choices both or all of which are believed to be equally wrong, resulting in the realization that it is impossible to “do the right thing” (Richards et al. 2020). An alternative definition may include a circumstance whereby an ethical response is clear but is difficult to act on because of anticipated undesirable consequences, such as client dissatisfaction or lost income (Morgan and McDonald 2007).

Types of Ethical Dilemmas

Veterinary professionals in practice encounter many types of ethical dilemmas, summarized in Table 7.2.

Frequency of Encountering Ethical Dilemmas

The majority of veterinarians experience an ethical dilemma at least once per week (Batchelor and McKeegan 2012; Kipperman et al. 2018; Lehnus et al. 2019; Quain et al. 2021). Although no study has examined how often veterinarians are subject to all of the conflicts listed in Table 7.2, the most common dilemma encountered by small animal veterinarians in one study was client financial limitations compromising patient care, with a median response of a few times a week (Kipperman et al. 2018). A recent study of veterinarians and veterinary technicians also found how to proceed with clients with limited finances as the most common dilemma (Quain et al. 2021). In small animal practice, euthanasia requests perceived to be based on lack of financial means occur with a median frequency of once a month, and euthanasia requests based on perceived client unwillingness to pay for treatment occur with a median frequency of a few times a year (Kipperman et al. 2018). These findings support the premise that financial concerns of animal owners are frequent causes of ethical conflicts for veterinarians.

Female veterinarians experience ethical dilemmas more frequently than males (Kipperman et al. 2018; Chun et al. 2019). These findings are in accord with a study documenting that female small animal veterinarians were more inclined to attempt treatment of animals in the face of economic limitations than males (Kondrup et al. 2016), and with reports that female students in animal science and veterinary programs had greater empathy for animals (Hazel et al. 2011; Colombo et al. 2016). It seems logical to propose that these characteristics would make one more likely to perceive an ethical dilemma. As the majority of those entering veterinary practice in the United States and the UK are female (Association of American Veterinary Medical Colleges 2019; Institute for Employment Studies Report 2019), this propensity to perceive ethical conflicts should be particularly concerning to the profession.

More experienced practitioners are less likely to report encountering an ethical dilemma (Kipperman et al. 2018; Wojtacka et al. 2020). It is reasonable to presume that with experience a practitioner would develop improved moral reasoning skills, but a study documented no improvement in moral reasoning of veterinarians in the UK with experience, which challenges this assumption (Batchelor et al. 2015). Alternatively, experienced practitioners over time may become desensitized to circumstances that novice colleagues may find ethically problematic.

Advocacy Behaviors of Veterinarians

There is limited scientific literature examining how veterinarians balance client and animal interests when these are at odds. In a quantitative study, 57% of small animal veterinarians described the conduct of their colleagues as prioritizing the interests of the client, and only 20% indicated that they believed other practitioners prioritize the interests of the patient (Kipperman et al. 2018). In contrast, 50% of these veterinarians reported their own behavior as prioritizing patient interests, while only 16% reported prioritizing the client’s interest. Corroborating these findings, in a study by Moses et al. (2018) 60% of veterinarians revealed they prioritized the needs of clients over patients. Another report found that only 48% of veterinarians and veterinary technicians believed that their primary obligation was to animal patients (Quain et al. 2021). A recent report discovered that while most small animal veterinarians in Europe agreed with a patient advocacy paradigm, a client-centered orientation was more prevalent than a patient-focused orientation (Springer et al. 2021). In another investigation, 92% of veterinary students indicated that veterinarians should prioritize patient interests when the interests of clients and patients conflict, whereas 84% of students reported that veterinarians most often prioritize client interests in these circumstances (Kipperman et al. 2020).

The evidence from the studies available casts doubt as to whether veterinarians are meeting societal expectations as advocates for animals. The stark contrast between the idealism focused on animal advocacy of veterinary students and their perceptions that a client-centered paradigm prevails in practice, creates potential for disillusionment and professional burnout. From a normative perspective, these findings should also prompt the profession to consider why many of its members’ behaviors do not reflect the ideals of its students. Concerted efforts to educate veterinary students and veterinarians about ethical dilemmas unique to the profession and their roles as animal advocates are warranted. Educators should also support the veterinarians’ role as animal advocate and prepare students for the contrast in advocacy preferences they are apt to encounter in practice.

The Case for a “Best Interest” or Patient Advocacy Paradigm

Numerous ethicists have proposed a “best interest” or patient advocacy model for veterinary medicine (Rollin 2006a; Grimm and Huth 2017; Coghlan 2018; Ashall et al. 2018; Thurner 2020). An ethics working party advised that companion animal practice be based on the principle of “in the animal’s best interest,” focused on two fundamental criteria: aiming to restore a patient’s health and respecting the patient’s quality of life (Grimm et al. 2018). Another definition of a “best interest” archetype advances this commitment, asserting that an animal is a patient only if the veterinary treatment provided intends to benefit their health-related interests for the animal’s own good and not for the purposes of others (Grimm and Huth 2017).

Coghlan (2018) takes this one step further and claims that patient advocacy should transpire, “even when advocacy may interfere with clients’ plans, wishes, and interests.” There have been numerous instances when I had the unenviable task during the holiday season of relaying a terminal diagnosis such as widespread cancer to a client regarding a patient who was suffering. A reasonably common client response was: “Can you make him comfortable until my children are home from college in two weeks so we can all say goodbye?” This challenging circumstance offers an opportunity for the veterinarian to live up to Coghlan’s standard by gently conveying the impact of the illness on the patient’s quality of life, advocating that a more appropriate timetable for consideration of euthanasia should be measured in hours or days rather than weeks. In more explicitly characterizing this paradigm, Thurner (2020) uses the example of an animal patient with a fractured limb. The only ethically acceptable outcome is facilitating repair of the break provided there is a good chance that quality of life can be restored. A euthanasia decision based on ending suffering or for the convenience of the animal owner would not be deemed acceptable outcomes.

Coghlan implores veterinarians to pursue “strong patient advocacy” (SPA), suggesting this is a philosophy of practice:

What distinguishes SPAs … is the preparedness to engage in the full gamut of justifiable advocacy options required for preventing harm to patients. Strong patient advocacy involves a disposition and a moral stance orientated toward the goal of improved patient wellbeing and an embrace of the range of justifiable ethical means and resources veterinarians have at their disposal.

(2018)

It has been asserted that improvements in animal welfare can only be furthered if veterinarians view animal advocacy as their primary raison d’être, and that acquiescing to the requests of animal owners may result in outcomes that may be detrimental to animal welfare (Kipperman 2017). Hernandez et al. (2018) make the welfare-based case for animal advocacy:

Advocating for animal welfare may not be comfortable and may, at times, require courage but is necessary … to improve human regard for animals as sentient beings. [Failure to do so] … can lead to an inability or difficulty in speaking up about concerns with clients and ultimately, failure in their duty of care to animals, leading to poor animal welfare outcomes.

Veterinarians manifest ambivalence as they navigate ethical conflicts involving clients and patients. Having a sense of clarity regarding one’s professional identity can act as a moral compass, helping to assuage the contextual inconsistencies inherent in veterinary practice. During the course of my career as an internist (often on an emotionally trying day when multiple patients had died), numerous students and interns have posed this thought-provoking question: “How do you determine whether you were a good veterinarian or had a successful day?” I tell them that defining success based on patient survival or death is unreasonable as there are so many factors influencing these outcomes that are beyond the control of the veterinarian. My response is simple: “Did I advocate for each of my patients to the best of my ability?” Or to use Coghlan’s term (2018), was I a “strong patient advocate?” Let’s now examine the obstacles to fulfilling this standard.

Limitations to a “Best Interest” or Patient Advocacy Paradigm

Veterinarians cannot directly obtain the medical wishes from their patients and are dependent on the animal owner acting as the patient’s agent. Therefore, pursuing a patient advocacy paradigm requires provision of informed consent to the owner, taking into account all available options for the patient including prognosis, potential benefits, risks, costs, and side effects of possible interventions (see Chapter 5 for a more thorough discussion). This is inevitably time consuming, and the limited duration of office visits in general small animal practice is a significant barrier to accomplishing this (Robinson et al. 2014; Corah et al. 2019).

Attempts to effect changes in practices regarding animal patients, such as advocating for management of patient obesity via dietary modifications, may be perceived by clients as offensive (Cairns-Haylor and Fordyce 2017). Discussing all of the available alternatives for the patient with the client, advising the option believed to provide the best chance for a positive result, and having the client regularly choose another option which the practitioner believes compromises patient outcome or prolongs poor quality of life can be emotionally draining and onerous. Consequently, pursuing a “patient best interest” model may be a metaphorical weight that becomes too heavy to lift for veterinarians over time, contributing to moral stress (see Chapter 22 for a more detailed discussion) (Springer et al. 2019). Grimm et al. (2018) argue that confronting moral stress is integral to the veterinarian’s responsibility. Huth (2020) acknowledges this risk and attempts to relieve this burden on the veterinarian:

Such [moral] distress often results from an exclusively animal-centered perspective and ethical demands for equal treatments of animals… It has a preventive effect against moral distress to be aware of the different obstacles for animal welfare and practical constraints that we [veterinarians] face… This awareness is not an abdication of responsibility but a prerequisite to acknowledging the … limits of veterinary responsibility – particularly for effecting ethical change.

A veterinarian’s capacity to pursue a “best interest” posture may reasonably be associated with their perception of autonomy within the culture and hierarchy of a particular practice. An intern, new graduate, new associate, or technician would be expected to have less independence to express their professional identity than a long-term associate or practice owner. As an example, I’ve had numerous colleagues tell me that they only feel comfortable referring patients to another hospital on days when their employer is not at the practice, due to intimidation. If a veterinarian feels subjected to hospital-based expectations that they are unable to overcome, this may negatively influence enactment of a “best interest” paradigm.

Veterinary care is becoming increasingly expensive (see Chapter 8 for a more detailed discussion of economic issues). The collaboration between veterinary professionals and animal owners requires discussion of the costs of tests and treatments, which may limit the viable choices. Unfortunately, pursuing a “best interest” model for small animal patients via the veterinary healthcare system is heavily reliant on the owner paying out of pocket, given the low prevalence of pet insurance (Kipperman et al. 2017). Clients may naturally be expected to select lower-cost options, especially if they do not understand why a costlier alternative may be more likely to result in a better outcome for their animal. Patient advocacy may be less ethically justifiable to pursue when a client expresses that they are unable to pay or if it is determined that such costs would be detrimental to them or their families (Coghlan 2018). Coghlan (2018) notes differing societal expectations regarding the financial obligations of animal owners compared with human parents:

it remains true that pediatricians enjoy comparatively more power over good patient health outcomes than do veterinarians. … this difference in authority is partly connected to the … moral point: that society holds parental responsibilities to surpass client responsibilities to animal companions. For example, we might well expect parents to risk serious financial hardship … to help their very ill children.

Clients also have the legal right to refuse well-intended veterinary counsel (Coghlan 2018). The legal status of animals as property (see Chapter 5) complicates any “best interest” paradigm as a foundation for veterinary decisions (Gray and Fordyce 2020). Gray and Fordyce have summarized the limitations of legal status and economics on patient advocacy quite nicely:

Direct comparisons between pediatric and veterinary decision-making require specific assumptions; first, that the owner regards the animal as having intrinsic value, and second, that there is an … acceptance of the subservience of the owner’s potential “selfish interests” … to the best interests of that animal. Because of the different … funding arrangements for treatment that protect children and animals from harm, this “selfish interest” concept may include resolution of the dilemmas surrounding the ability or desire of the owner to fund any potential treatment.

(2020)

Communication

To be an animal advocate, one must be able to effectively communicate with their human owners and caretakers to educate them, and to inspire trust and confidence in the veterinary professional as both a caring and knowledgeable figure. This can be especially challenging for new graduates (Haldane et al. 2017). An association between communication skills and client compliance with veterinary recommendations reflects my own experience and has been documented (Kanji et al. 2012). Consequently, a veterinarian may blame the client for failing to adhere to professional guidance rather than ineffective communication on the part of the practitioner.

Veterinarians appear to routinely make judgments about their clients including categorizing them as “good” or “bad” in terms of inclination to pursue treatments or pay the fees (Morgan 2009). Therefore, if a veterinarian presumed that a client could not afford diagnostic testing or would not pay for it, testing may not be offered. A study corroborates this, finding that approximately a third of small animal veterinarians indicated that they do not offer ideal diagnostic or treatment options in the list of alternatives provided to all clients (Kipperman et al. 2017). Limiting provision of options due to classification of clients can compromise both patient advocacy and the veterinarian’s capacity to promote animal welfare (Hernandez et al. 2018).

Morgan and McDonald suggest that practitioners should attempt to discern the bond clients have with their pet (2007). This may involve encouraging clients to share information regarding their emotional attachment to the patient, their mutual experiences, and the animal’s role in the household (Coghlan 2018). In challenging circumstances, veterinary professionals may find it necessary to discuss their duties with clients including easing animal suffering (Morgan and McDonald 2007). It is argued that there should be limits to the extent to which veterinarians should grant client requests:

Veterinarians should feel comfortable in drawing boundaries by indicating … what they consider to be inappropriate solutions to a problem. … it may be possible to develop hospital policies around issues that occur frequently… Common problem situations may be discussed during practice meetings to develop … policies that all members of the veterinary team can support. Establishing these boundaries … may also minimize moral stress to practitioners.

(Morgan and McDonald 2007)

In certain settings, negotiating with clients may be warranted to achieve the best outcome for patients. As an example, a client may not be motivated by the veterinary professional’s divulged concern that the patient is gaining weight, is now overweight, and requires dietary modifications. Instead of being discouraged and giving up, the veterinary professional can instead attempt to strike a “bargain” with the client: “Mrs. S, can we agree that you’ll bring Buffy by for another weight check in a month at no charge, and if she continues to gain weight, we’d agree to change her diet then?”

Is Client Persuasion Acceptable?

Physicians and veterinarians share a formidable authority entrusted to those that society recognizes as healers (Rollin 2002). Scholars agree that such influence should be used to promote the patient’s best interests and that pursuit of any other objective signifies taking advantage of that authority (Rollin 2002; Yeates and Main 2010; Shaw and Elger 2013). For example, Plato observed that one’s role as a healer should not be influenced by one’s role as a businessperson (Rollin 2002). A patient advocacy position should also support the idea that clients have the right to have their autonomy respected as an essential tenet of veterinary practice. This principle of recognition of autonomy in medical ethics has been the basis for the belief that it is unethical to persuade or change a patient’s (or client’s in veterinary medicine) decision, because doing so could represent intimidation, paternalism, or exploitation (Rubinelli 2013; Shaw and Elger 2013). Rosoff et al. (2018) dispute this assertion, suggesting that owners are not omnipotent and that veterinarians have a moral authority, which can influence client decisions regarding their animals. The challenge for veterinarians is to provide enough information to facilitate informed consent from the owner and to advocate for the patient, while not inflicting one’s own beliefs that may incur approval of a degree of risk that is untenable for the client (Fettman and Rollin 2002).

Scholars (Barilan and Weintraub 2001; Shaw and Elger 2013) argue that persuasion is an integral part of medical practice. Barilan and Weintraub contend that clinicians are obligated to influence their patients:

healthcare professionals are obliged to try to persuade their patients to accept medical advice in order to expedite medical outcome … if a physician wishes to act with respect for the person of his or her patient, the physician must participate in a conversation in which he or she will do his or her best to persuade the patient to consent.

(2001)

If we extend this conclusion to the profession of veterinary medicine, then veterinarians have a moral duty to encourage their clients to pursue what the clinician believes to be the best medical advice for the patient. Exerting influence may be more readily justified when clients want to be influenced. Yeates and Main (2010) observe that many clients want their veterinarian to help them make decisions by sharing their expertise and views. In this paradigm of “ethical persuasion” it would be reasonable for a practitioner to reveal their recommended course of action or to state what they would do in the same situation when clients ask “What would you do, Doctor?” One author advances this idea by contending that physicians who do not disclose their suggested plan are depriving patients of pertinent knowledge and are therefore limiting their capacity to grant informed consent (Shaw and Elger 2013).

Coghlan (2018) argues that there are limits to clinician persuasion: “Coercing or intimidating guardians … is both illegal and wrong. … while veterinarians may well advocate assiduously and creatively for patients, they are not typically entitled to lie to, seriously deceive, or coerce clients (except by invoking the law), even to protect their patients’ vital interests.”

Ultimately, the decision of when it is appropriate to influence a client must be left to the practitioner. Some veterinary ethicists contend that exerting influence is most compelling when the client makes a decision that the veterinarian deems to be unreasonable relative to the animal’s best interest (Rollin 2006a; Yeates and Main 2010). As an example of when persuasion should be exercised, Rollin (2002) argues for leveraging the authority of the veterinarian when faced with requests to euthanize healthy animals:

the only escape from moral stress in the context of demands for convenience euthanasia is to do everything in one’s power to save that animal, including exerting one’s Aesculapian authority as forcefully as possible. Thus, it is well within the role of veterinarian as healing professional to deploy his or her Aesculapian authority to keep a healthy animal alive.

Ethics Instruction

Ethics education in veterinary school may improve capacity to recognize ethical conflicts and provide approaches that facilitate ethical decision-making (Hernandez et al. 2018). The need for ethics instruction for veterinarians has been examined. A survey found that only 45% of Australian veterinary students agreed that they were proficient in ethical decision-making abilities to guide views on animal ethics issues (Verrinder and Phillips 2014), and in another survey only about 25% of Australian veterinarians agreed that the behavior of colleagues is consistent with the ethics of the profession (Heath 2002). Despite these findings, training in ethics for veterinary students is not uniformly available.

Only 30% of AVMA-accredited veterinary schools in the United States that responded to a survey reported to offer a formal course in ethics (Shivley et al. 2016). Recent studies found that 51% of US small animal practitioners reported having received ethics training in their curriculum (Kipperman et al. 2018), 29% of North American veterinarians received instruction in resolving conflicts about what is best care for patients (Moses et al. 2018), and only 20% of Korean veterinarians participated in ethics training programs (Chun et al. 2019). Rawles (2000) agrees with these findings, observing that “vets … are … on an ethical high-wire, constantly balancing their concern with animal welfare against the demands of the industries, clients and practices they work for, without having been given any training in how to do this.”

Regarding the effectiveness of ethics education, results are inconclusive. Only 39% of small animal veterinarians who had received ethics instruction in veterinary school agreed that such training prepared them to address ethical dilemmas (Kipperman et al. 2018). This finding differs from the opinions of most first-year Australian veterinary students, who agreed that training they received to assist them in making ethical decisions was beneficial for illuminating their own or others’ positions, and for improving moral reasoning abilities (Verrinder and Phillips 2014). The most recent study on this topic found that 78% of US veterinary students from four schools reported having received training in ethical theories and approaches to address ethical dilemmas (Kipperman et al. 2020). These results were more optimistic, finding that 80% of students agreed that they feel better prepared to identify ethical dilemmas they may encounter as veterinarians as a result of their ethics training, and 55% agreed that they felt better prepared to address ethical dilemmas as a result of their ethics training.

The available evidence suggests that students are more likely to believe their ethics training has prepared them to address ethical dilemmas compared with practitioners. One explanation for this is that ethics instruction may be better at promoting ethical competencies than in the past. A report has documented the success of student-centered, case-based scenarios and discussion in ethics education (Magalhães-Sant’ Ana et al. 2016). Alternatively, as students become practitioners, they may forget or fail to use the ethical principles they were taught in school. The finding that 95% of veterinary students in a recent study felt that veterinary ethics should be taught in the veterinary curriculum also corroborates the value of ethics instruction (Kipperman et al. 2020). On the basis of these findings, ethics training should be a core component of the veterinary curriculum. Postgraduate educational opportunities in ethics are warranted and may help to retain the perceived value of ethics instruction.

Methods to Address Ethical Conflicts

Just as veterinarians are taught to use a problem-oriented or subjective, objective, assessment, and plan (SOAP) system to improve capacity to formulate a diagnostic and therapeutic plan for patient care, utilizing a systematic approach is advised to address ethical problems (Case Study 7.1). Such frameworks do not necessarily provide a right or wrong answer but are intended to guide discussion of pertinent veterinary ethical concerns and facilitate ethical problem-solving (Grimm et al. 2018). A study of small animal veterinarians discovered that gut instinct based on their personal value system was the most common method utilized to address ethical dilemmas, while guidance from written policies of state or national veterinary organizations, and consideration of varied ethical theories, were least often used (Kipperman et al. 2018). A recent study of veterinarians and veterinary technicians found that discussion with colleagues was the most commonly reported method to help address ethical dilemmas: only 25% referred to codes of conduct and 15% utilized ethical frameworks (Quain et al. 2021). It appears that veterinarians are not using step-by-step frameworks in their everyday ethical decision-making. An approach I have applied with success and teach veterinary students is shown in Table 7.3. A more elaborate methodology, the veterinary ethics tool (VET), has also been proposed (Grimm et al. 2018) (see Table 23.2).